You are developing a care plan for Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include?
A. Administering a lactulose enema as ordered.
B. Encouraging a protein-rich diet.
C. Administering sedatives, as necessary.
D. Encouraging ambulation at least four times a day.
Correct Answer: A. Administering a lactulose enema as ordered.
You may administer the laxative lactulose to reduce ammonia levels in the colon. Elevated ammonia levels disrupt the balance of excitatory and inhibitory neurotransmitters, further exacerbating neurological and motor function decline (Felipo, 2013). Patients who have high ammonia levels can experience HE, but in chronic liver failure, a higher ammonia level does not predict a more severe degree of HE.
Option B: Protein restriction is reserved for patients who are severely protein-intolerant or for very short periods for patients with GI bleeding until symptoms resolve (Amodio et al., 2013). Dairy and vegetable proteins are preferred but are usually much less palatable. A fiber-rich diet is recommended to encourage fecal ammonia excretion while avoiding diarrhea that could potentially induce HE in patients already taking lactulose.
Option C: It is suggested to proceed with caution when prescribing and administering any opioids for pain management because of their high-risk effects on the patient with chronic liver disease like sedation, constipation, and confusion, which are precipitating factors to induce HE. Doses may need to be lower with longer intervals between these doses for patient safety.
Option D: Asterixis (flapping tremor), muscle twitching, and hyperreflexia may be observed in patients with OHE. These can be accompanied by other neuromuscular impairments such as bradykinesia and hyperactive deep tendon reflexes. Bradykinesia means “slow movement” and can present as decreased facial expressions, increased stillness, or difficulty with performing repetitive tasks such as finger tapping.
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